Risk Adjustment coding reviews can take many different shapes and forms.  When starting a new project/review, there are many things to consider.  A “Project Management” approach is key to success.  Project Management includes four phases:  Project Planning Phase; Project Build-up Phase; Project Implementation Phase; and Project Completion & Closure Phase.   In this article we will address the Risk Adjustment Review best practices using a Project Management approach.

Project Planning Phase:  In this phase it’s important to lay out the why’s and how’s to the project.  Why are we doing it and how are we going to get it done.  Below is an outline:

  • Identify Stakeholders:  Stakeholders can be various depending on the size of the organization and the anticipated benefits or results from the review.  They are the individuals in an organization that will be impacted by the outcome of this review, or whose resources are necessary to perform the review (staff, tools, information and money).
  • Define Objectives:  Simply why are we doing this review?  For overall compliance?  To find errors in codes that were submitted?  To find diagnoses not previously submitted?  To educate Providers in HCC code capture?  To find missing revenue?
  • Define Project Scope:  The below items are typically needed to define the project scope:
    • Dates of service – What dates of service (or timeframe) for charts will be reviewed
    • Payors – Which payors (insurance type) will be reviewed
    • Volume — How many charts/patients will be reviewed
    • Review Approach – This part is very important and can vary immensely but is necessary to delineate.  What specifically will be reviewed, what capture points or items will be gathered.  Additionally, what other tasks that will be required of the team?  It is important to know exactly what the project entails, as this will enable planning for staffing and training.
    • Staffing requirements – This can be calculated using an estimated charts per hour or patients per hour calculation.  Knowing staffing requirements is important because if understaffed, the job will not get completed on schedule.
    • Completion due date – When is the project to be completed?  After lining out the volume of work to be audited, and the productivity anticipated, it will be clear how many Auditors will be needed to complete the project on time.
    • Cost/Budget – Estimated cost for such review can be made based upon the volume to be reviewed, divided by the estimated productivity, multiplied by the average cost per hour of the auditors.  In estimating cost, also include costs of individuals who run reports, perform quality reviews, organize and prepare final reports of findings, and presenting or education to staff.
    • Scaling of Project – Depending on the budget, scaling of the project may be in order.  Rescoping of volumes to review would be the initial area to analyze.

Project Build-Up Phase:  In this phase, the Audit Team is assembled, approach and timelines are solidified.

  • Assemble Audit Team:  It is important that the Auditors are the right fit for the review.  Having Coding Auditors that are experienced and credentialed will ensure they have top notch knowledge and skills to perform the review.  Depending on the size of the Team, quality control must be considered, and who will perform these quality reviews.  Additionally, Team oversight and management must be considered as well. 
  • Audit Approach:  A thorough, and well thought out audit approach is also critical to the success of a review.  Below are the steps to ensure a successful review:
    • Patient/Chart to Review:  To identify patients/charts to be included in a review, a comprehensive report typically can be created by Information Technology.  This report will show the entire universe of claims or patients enrolled in a given timeframe.  From this report, patients/charts can be selected to be reviewed (or a sampling can be selected for the review). 
    • Review Tools:  Review tools or software are critical to the capture and storage of review results.  Software or technology can be used to gather data, but also, a simple excel report can be utilized.
    • Anticipated Final Reports:  What does leadership or the stakeholders want to see in the final reports.  Be sure the information wanted in final reports is extracted during the review process and in the capture of results.  
    • Patient Records:  To perform all coding related risk adjustment reviews, access to patient record is necessary.  If within the organization – access to records can be done via electronic access (assuming the organization has an Electronic Health Record).  If records are from entities outside of the organization, that is a bit more tricky as request for records will be required.  Access for auditors will need to be performed, and/or copies of records requested. 
    • Coding Review Instructions/Guidelines:  Even if there are experienced and credentialed auditors, detailed written instructions are important to have in place.  Also written coding guidelines, specific to the organization are critically important.  There are many gray areas in coding – an organizations interpretation and stance on these issues is important for consistent coding   review results.
  • Project Timelines: Timelines, mid-point completion goals and completion goals are all important to have delineated.  To know an end date or completion goal is key to staffing (you will hire more/less auditors depending on the timeline).  The timeline ties in with the budget.  Typically, a review with a shorter timeline (with large volume) will be a higher rate per chart than a longer timeline (due to potential of required overtime to hit goals). 

Written by Dana Brown, MBA RHIA, CHC, CCDS, CRC, President & Dott Campo, RHIT, CRC, Manager, Risk Adjustment Division